Information Collection

Authorization For Release Of Medical Information

IC 263822 under ICR 202312-1123-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1123-0NEW Release form.Mental Health (ARI).docx [email protected]	Other-Release Form

IC Title:

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 28 CFR 1.1 28 CFR 0.36 28 CFR 0.35

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Release Form			1123-0NEW Release form.Mental Health (ARI).docx	[email protected]	Yes	Yes	Fillable Fileable

Line of Business: Correctional Activities

Subfunction: Criminal Rehabilitation

Privacy Act System of Records

Title: Executive Clemency Case Files/Executive Clemency Tracking System

FR Citation: 76 FR 57078

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	441	441

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.